K. V. Ramani

Health system in India: opportunities and challenges for improvements

PURPOSE The paper seeks to show that health and socio-economic developments are so closely intertwined that is impossible to achieve one without the other. DESIGN/METHODOLOGY/APPROACH This paper sees that building health systems that are responsive to community needs, particularly for the poor, requires politically difficult and administratively demanding choices. Health is a priority goal in its own right, as well as a central input into economic development and poverty reduction. FINDINGS The paper finds that, while the economic development in India has been gaining momentum over the last decade, the health system is at a crossroads today. Even though Government initiatives in public health have recorded some noteworthy successes over time, the Indian health system is ranked 118 among 191 WHO member countries on overall health performance. ORIGINALITY/VALUE This working paper describes the status of the health system, discusses critical areas of management concerns, suggests a few health sector reform measures, and concludes by identifying the roles and responsibilities of various stakeholders for building health systems that are responsive to the community needs, particularly for the poor.

Health policy processes in maternal health: A comparison of Vietnam, India and China

This article reports on a comparative analysis to assess and explain the strengths and weaknesses of policy processes based on 9 case-studies of maternal health in Vietnam, India and China. Policy processes are often slow, inadequately coordinated and opaque to outsiders. Use of evidence is variable and, in particular, could be more actively used to assess different policy options. Whilst an increasing range of actors are involved, there is scope for further opening up of the policy processes. This is likely, if appropriately managed with due regard to issues such as accountability of advocacy organisations, to lead to stronger policy development and greater subsequent ownership; it may however be a more messy process to co-ordinate. Coordination is critical where policy issues span conventional sectoral boundaries, but is also essential to ensure development of policy considers critical health system and resource issues. This, and other features related to the nature of a specific policy issue, suggests the need both to adapt processes for each particular policy issue and to monitor the progress of the policy processes themselves. The article concludes with specific questions to be considered by actors keen to enhance policy processes.

The transition of childbirth practices among tribal women in Gujarat, India - a grounded theory approach

BackgroundUnder the National Rural Health Mission, the current emphasis is on achieving universal institutional births through incentive schemes as part of reforms related to childbirth in India. There has been rapid progress in achieving this goal. To understand the choices made as well as practices and perceptions related to childbirth amongst tribal women in Gujarat and how these have been influenced by modernity in general and modernity brought in through maternal health policies.MethodA model depicting the transition in childbirth practices amongst tribal women was constructed using the grounded theory approach with; 8 focus groups of women, 5 in depth interviews with traditional birth attendants, women, and service providers and field notes on informal discussions and observations.ResultsA transition in childbirth practices across generations was noted, i.e. a shift from home births attended by Traditional Birth Attendants (TBAs) to hospital births. The women and their families both adapted to and shaped this transition through a constant ’trade-off between desirable and essential’- the desirable being a traditional homebirth in secure surroundings and the essential being the survival of mother and baby by going to hospital. This transition was shaped by complex multiple factors: 1) Overall economic growth and access to modern medical care influencing women’s choices, 2) External context in terms of the international maternal health discourses and national policies, especially incentive schemes for promoting institutional deliveries, 3) Socialisation into medical childbirth practices, through exposure to many years of free outreach services for maternal and child health, 4) Loss of self reliance in the community as a consequence of role redefinition and deskilling of the TBAs and 5) Cultural belief that intervention is necessary during childbirth aiding easy acceptance of medical interventions.ConclusionIn resource poor settings where choices are limited and mortality is high, hospital births are perceived as increasing the choices for women, saving lives of mothers and babies, though there is a need for region specific strategies. Modern obstetric technology is utilised and given meanings based on socio-cultural conceptualisations of birth, which need to be considered while designing policies for maternal health.

Do the pre-service education programmes for midwives in India prepare confident 'registered midwives'? : A survey from India

Objective The graduates of the diploma and degree programmes of nursing and midwifery in India are considered skilled birth attendants (SBAs). This paper aimed to assess the confidence of final-year students from pre-service education programmes (diploma and bachelors) in selected midwifery skills from the list of midwifery competencies of the International Confederation of Midwives (ICM). Design A cross-sectional survey was conducted in Gujarat, India, involving 633 final-year students from 25 educational institutions (private or government), randomly selected, stratified by the type of programme (diploma and bachelors). Students assessed their confidence on a four-point scale, in four midwifery competency domains – antepartum, intrapartum, postpartum, and newborn care. Explorative factor analysis was used to reduce skill statements into separate subscales for each domain. Results Overall, 25–40% of students scored above the 75th percentile and 38–50% below the 50th percentile of confidence in all subscales for antepartum, intrapartum, postpartum, and newborn care. The majority had not attended the required number of births prescribed by the Indian Nursing Council. Conclusions The pre-service education offered in the diploma and bachelors programmes in Gujarat does not prepare confident SBAs, as measured on selected midwifery competencies of the ICM. One of the underlying reasons was less clinical experience during their education. The duration, content, and pedagogy of midwifery education within the integrated programmes need to be reviewed.

The Effect of Surveillance and Appreciative Inquiry on Puerperal Infections: A Longitudinal Cohort Study in India

Objective To evaluate the effects of an intervention comprising surveillance and an organisational change called Appreciative Inquiry on puerperal infections in hospitals in Gujarat state, India. Methods This longitudinal cohort study with a control group was conducted over 16 months between 2010 and 2012. Women who delivered in six hospitals were followed-up. After a five month pre-intervention period, the intervention was introduced in three hospitals. Monthly incidence of puerperal infection was recorded throughout the study in all six hospitals. A chi-square test and logistic regression were used to examine for associations, trends and interactions between the intervention and control groups. Findings Of the 8,124 women followed up, puerperal infections were reported in 319 women (3.9%) over the course of the study. Puerperal sepsis/genital tract infections and urinary tract infections were the two most common puerperal infections. At the end of the study, infection incidence in the control group halved from 7.4% to 3.5%. Levels in the intervention group reduced proportionately even more, from 4.3% to 1.7%. A chi-square test for trend confirmed the reduction of infection in the intervention and control groups (p<0.0001) but the trends were not statistically different from one another. There was an overall reduction of infection by month (OR = 0.94 95% CI 0.91–0.97). Risk factors like delivery type, complications or delivery attendant showed no association with infection. Conclusion Interruption of resource flows in the health system occurred during the intervention phase, which may have affected the findings. The incidence of infection fell in both control and intervention groups during the course of the study. It is not clear if appreciative inquiry contributed to the reductions observed. A number of practical and methodological limitations were faced. Trial Registration Controlled-Trials.com ISRCTN03513186

A GIS approach to plan and deliver healthcare services to urban poor

Purpose – To provide a public private partnership (PPP) model for urban health centres (UHC) in developing countries that can be useful for urban local governments and private service providers willing to enter into meaningful partnerships so as to improve primary healthcare services.Design/methodology/approach – This research is based on geographical information system methodology to identify suitable locations to address availability, access, affordability and equity concerns and to provide a practical framework for PPP for establishing UHC. The methodology involved survey and mapping of slum communities and private healthcare facilities.Findings – The research provides intricate details about planning healthcare services for urban poor, operational and managerial aspects of service provision and processes involved in PPP for urban health.Research limitations/implications – The model is developed and tested for Ahmedabad city (sixth largest city in India) and may need a certain amount of customisation f...

Using 'appreciative inquiry' in India to improve infection control practices in maternity care: a qualitative study.

Background Infections acquired during childbirth are a common cause of maternal and perinatal mortality and morbidity. Changing provider behaviour and organisational settings within the health system is key to reducing the spread of infection. Objective To explore the opinions of health personnel on health system factors related to infection control and their perceptions of change in a sample of hospital maternity units. Design An organisational change process called ‘appreciative inquiry’ (AI) was introduced in three maternity units of hospitals in Gujarat, India. AI is a change process that builds on recognition of positive actions, behaviours, and attitudes. In-depth interviews were conducted with health personnel to elicit information on the environment within which they work, including physical and organisational factors, motivation, awareness, practices, perceptions of their role, and other health system factors related to infection control activities. Data were obtained from three hospitals which implemented AI and another three not involved in the intervention. Results Challenges which emerged included management processes (e.g. decision-making and problem-solving modalities), human resource shortages, and physical infrastructure (e.g. space, water, and electricity supplies). AI was perceived as having a positive influence on infection control practices. Respondents also said that management processes improved although some hospitals had already undergone an accreditation process which could have influenced the changes described. Participants reported that team relationships had been strengthened due to AI. Conclusion Technical knowledge is often emphasised in health care settings and less attention is paid to factors such as team relationships, leadership, and problem solving. AI can contribute to improving infection control by catalysing and creating forums for team building, shared decision making and problem solving in an enabling environment.

Why Should 5,000 Children Die in India Every Day? Major Causes of Death and Managerial Challenges

Globally, more than 10 million children, under five years of age, almost all in poor countries, die every year (20 children per minute), mostly from preventable causes. The major causes of child death include neonatal disorders (death within 28 days of birth), diarrhoea, pneumonia, and measles with malnutrition being a major contributing factor for childhood illnesses. India alone accounts for almost 5,000 deaths of under-five years children (U5) every day. In 1975, the Integrated Child Development Scheme (ICDS) was launched in the country to provide integrated health and nutrition services focusing upon the holistic development of children at the village level. Yet by 2005, 50 per cent of the children in India were still malnourished. Indias neonatal mortality, which accounts for almost 50 per cent of the U5 deaths, is one of the highest in the world. India launched the Universal Immunization Programme (UIP) in 1985. Yet full immunization in India had reached only 43.5 per cent by 2005-06, as per the NFHS 31. This paper, besides discussing the status of mortality of children and the situation of child health services, examines the managerial challenges of the child health programmes in India. There is a need for improving the management capacity amongst health service providers, specifically the planning and implementation of child health programmes such as immunization, control of diarrhoea, and pneumonia. The analysis of the trends of the past decline shows that during 1990-2008, India achieved a decrease in infant mortality rate (IMR) at a very low annual average rate of 1.9 per cent. To achieve Millennium Development Goals (MDG) 4, between 2009— 2015, the rate of reduction of IMR needs to be increased to a very high level — at 6.74 per cent every year. This means that the government and the private sector need to improve the effectiveness and efficiency of the child health programmes substantially. Incremental improvement over “business-as-usual” will not help in achieving MDG 4. Effective and efficient management of child health programmes would require focused political and administrative attention and managerial capacity.